ethical challenges in biofeedback practiceethical challenges: resolving ethical issues • a...

ETHICAL CHALLENGES IN

BIOFEEDBACK PRACTICE

Donald Moss, PhD (2016)

ETHICAL CHALLENGE: CHOICE OF TREATMENT

• John Q, PhD, BCB, a BCIA certified psychologist, was enthused with heart rate variability biofeedback. He informed a new patient, Ms. Cindy G., that HRV is now the state of the art treatment nationwide for panic attack.

• The patient struggled with the technology and computer interface, which are difficult for her. After 6 weeks, she dropped out of treatment. Six months later, John Q received a notice from her attorney that Ms. G was successfully treated with cognitive behavioral therapy and an SSRI.

ET HI CAL CHAL L ENG E: CHO I CE O F T REAT MENT (CO NT. )

• She sued Dr Q for misinforming her about the current research, and providing an experimental therapy when empirically supported therapies were available.

• Describe some steps that Dr. Q. could have taken to avoid this lawsuit.

ETHICAL CHALLENGE: INAPPROPRIATE TOUCH

• Arthur K., PhD, BCB, a licensed psychologist and certified biofeedback practitioner, emphasized teaching diaphragmatic breathing for anxiety management. He instructed a female client, Alice W., to place her hand over her abdomen, to feel the process of respiration. When she struggled to learn diaphragmatic breathing, he asked her permission to place his hand over hers on the abdomen. He used moderate pressure to increase her awareness of the expansion and contraction of the abdomen during breathing.

ETHICAL CHALLENGE: INAPPROPRIATE TOUCH

• Alice W. later filed a complaint with her HMO, stating that Dr. K. had touched her inappropriately.

• Did Dr. K. commit an ethical violation or do anything professionally inappropriate? Was there some step he could have taken to avoid this situation?

ET HI CAL CHAL L ENG E: I NAPPRO PRI AT E TO UCH: PART I I

• Howard P., PhD, BCB, a licensed psychologist and certified biofeedback practitioner, also taught diaphragmatic breathing for anxiety management. He instructed a female client, Genevieve T., to place her hand over her abdomen, to feel the process of respiration. She later filed a complaint with the state psychology licensing board, stating that he had caused her to touch herself in a sexually inappropriate way.

• Discuss this incident as a possible ethical violation? Should Dr. P. have behaved differently?

ET HI CAL CHAL L ENG E: PELV I C F L O O R B I O F EEDBACK

• Pelvic Floor Biofeedback utilizes EMG sensors inserted into the vagina and rectum, along with pressure sensors inserted into the same areas, to train the patient to correct maladaptive patterns of muscular tensing. Women with urinary incontinence, men and women with fecal incontinence, women with chronic vulvovaginal pain, and men and women with anorectal pain can all benefit from this form of biofeedback. Placements of the sensors, in areas seen as “private” is a challenge.

ET HI CAL CHAL L ENG E: PELV I C F L O O R B I O F EEDBACK

(CO NT ) .

• Many practitioners in the pelvic floor area are female nurses, and both their medical role and their gender render most patients more comfortable.

• Yet several well-trained male social workers and psychologists also provide pelvic floor biofeedback. Consider what measures these individuals can undertake to protect the patient’s

modesty, and protect themselves against allegations that they have exceeded their professional scope of practice.

ET HI CAL CHAL L ENG ES: RESO LVI NG ET HI CAL I SSUES

• A psychologist, Dr. Valdez, received a referral for marital therapy from a Mr. Martin, a social worker and certified biofeedback practitioner

• Husband and wife were seen separately for assessment

• In the course of his session, the husband disclosed that the trigger for the marital crisis was the wife’s affair with the

biofeedback practitioner


• Dr. Valdez immediately filed a complaint with the state licensing board against Mr. Martin, and phoned the local police department to open charges against him

• Dr. Valdez disclosed the incident to several colleagues at an area psychological association meeting, and cautioned them not to refer to the biofeedback practitioner


(CO NT. )

• When Valdez interviewed the wife, she denied any affair, but admitted provoking the husband’s

jealousy with suggestive comments

• Dr. Valdez accused the wife of lying and warned her that he would “make sure Mr. Martin pays for what he did”

• Mr. Martin was contacted by the police, who opened an investigation

• He retained a criminal attorney


(CO NT. )

• The criminal investigation ceased when Ms. Lane denied all allegations

• Mr. Martin later received a notification of investigation by the licensing board, and retained a second attorney

• The licensing board process was terminated three months later, when Ms. Lane refused to discuss the matter with the Board investigator


(CO NT. )

• Mr. Martin experienced significant loss of referrals and financial strain

• Several referring pastors and physicians told him that “everyone knows about” affair with Ms. Lane

• Ms Lane resumed biofeedback therapy with Mr. Martin, reported that Dr. Valdez threatened to make Mr. Lane “pay for what he has done”

• Mr. Lane’s second attorney sent a notice of civil

suit against Dr. Valdez

ETHICAL CHALLENGE: INFECTION CONTROL

• Kathleen M., LCSW, a licensed clinical social worker and non-certified biofeedback practitioner, attended a workshop on EEG treatment of attention deficits and becomes enthused. She purchased an older EEG system on Craigs List, and opened a practice in treating attention disorders. The EEG system used sponge electrodes, which conduct the electrical signal via salt water infused sponges, placed on the skin. She read the instrument manual, read two books chapters about EEG biofeedback treatment, and attended no workshops.

ETHICAL CHALLENGE: INFECTION CONTROL(CONT. )

• After four months in providing EEG biofeedback treatment, she treated a high school wrestler, Eric S., with red raised blotches on his forehead and scalp.

• Eric told her that the blotches are “nothing,” that all of

the wrestlers have them. Within two weeks, three others among Ms. M.’s patients developed similar rashes. One of the

mothers threatened to file a complaint, and asked Ms. M. to pay for her son’s medical care.

• The blotches were diagnosed as Impetigo, a contagious bacterial skin condition. The eruptions are usually on the torso, but in this case were probably spread on the team’s

wrestling mats.

ETHICAL CHALLENGE: INFECTION CONTROL(CONT. )

• Discuss ethical aspects of Ms. M.’s actions. How

might she have minimized the risk of infection? Did she breech any specific ethical guidelines?

ET HI CAL CHAL L ENG ES: DUAL O R MULT I PL E

REL AT I O NSHI PS

• Paul Morgan, PhD, BCB, a psychologist and certified biofeedback practitioner, regularly provided mentoring for professionals preparing for BCIA certification.

• Mindy B. paid for 16 hours of biofeedback mentoring.


REL AT I O NSHI PS (CO NT. )

• Mindy B. was impressed with Paul Morgan’s

therapeutic skills, and scheduled an appointment to see him for psychotherapy, regarding the breakup of her marriage.

• He was very supportive of Mindy in therapy, encouraging her to believe in herself, and to try new activities. She felt great personal renewal and left her spouse.



• Mindy B. was grateful to Dr. M. and sent several of her friends to him for psychotherapy and biofeedback.

• One year later, Mindy B. completed her preparations for the BCIA certification. She asked Dr. M. for a letter supporting her certification, based on the 16 hours of mentoring she had purchased from him.



• Dr. M. declined to support her readiness for certification. He stated in a letter to BCIA that she had shown a lack of progress in the 16 hours of mentoring.

• Dr. M. further stated in his letter that Mindy B. confused the physiological signals that the instruments were recording, and didn’t seem to

be able to grasp the scientific standards involved in research on biofeedback.



• Mindy B. was devastated. He had seemed so supportive in therapy, and she never imagined that he would not support her candidacy for certification. She filed a complaint with his state licensing board.

• Discuss ethical aspects of this situation, and steps that Dr. M. might have taken to avoid a problem.

ET HI CAL CHAL L ENG ES: D I SCL O SURE O F I NF O RMAT I O N

• Susan L., PA, BCB, physician’s assistant and BCIA

certified practitioner, provided general biofeedback in integrative medicine clinic. She specialized in biofeedback for headache disorders and stress related conditions in children and adolescents.

• Susan L. treated anxious and troubled 12 year old girl, Madeline D., with migraine headaches.


• Madeline responded positively, learning to warm her hands and relax the musculature of her neck and shoulders. The headaches decreased in intensity.

• After five weeks, Madeline’s progress ceased. She

seemed more distraught, tearful at times, but refused to discuss any basis for the tears.


(CO NT. )

• Susan L. invited Madeline’s father in to speak

with her after the session, and he tearfully disclosed that he was having an affair, and that Madeline had encountered him with his girlfriend.

• Susan L. used this information to open discussion with Madeline about her fears for her parents’

marriage. Several weeks later she terminated her counseling with headaches much reduced and her emotions calmer.


(CO NT. )

• Six months later, Susan L. received a subpoena from an attorney for Madeline’s mother, requesting all records on Madeline’s treatment. Susan

complied with the subpoena, and provided all records, including her “process note” on

conversations with the father about his affair.


(CO NT. )

• Mr. D’s attorney in turn, filed a lawsuit

against Susan L. for disclosing his confidential information to his estranged wife without his permission.

• Discuss the ethical aspects of this situation, and of Susan L.’s actions.

ethical challenges in biofeedback practiceethical challenges: resolving ethical issues • a...

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